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Whittier Hospital Medical Ctr D/P SNF

9080 Colima Road, Whittier, CA 90605 · For profit - Corporation · 22 certified beds · (562) 945-3561 Medicare & Medicaid certified

Call the home — (562) 945-3561 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0605) — cited Jun 20262 actual-harm citations
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (5/5)
  • lower-than-typical staff turnover (29% vs 45% nationally) — better care continuity
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 2 actual-harm citations
  • a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

5/5
CMS overall
5 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 5 of 5
Quality measuresSelf-reported by the facilityNot rated

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
15111 Whittier Blvd #102 · (562) 945-6440 · Call to confirm hours
Pharmacy
9209 Colima Rd Ste 1100 · (562) 943-7500 · Call to confirm hours
Grocery
15025 Whittier Blvd · (562) 698-1642 · Call to confirm hours
Park
16200 Las Cumbres Dr · (562) 567-9420 · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measuresNot rated

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 4 to 5 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating5★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents who lose too much weight6.5%4.0%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.8%0.9%better
Long-stay residents with a urinary tract infection7.8%1.2%2.0%worse
Long-stay residents with depressive symptoms0.0%7.3%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.4%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury0.0%1.6%3.3%check this — see note marked star below the table
Long-stay residents on antianxiety or hypnotic medication57.1%13.7%18.9%check this — see note marked dagger below the table
Long-stay residents with pressure ulcers0.0%4.3%4.7%check this — see note marked star below the table
Long-stay residents with worsening bladder/bowel control2.3%10.2%21.2%better than state — see note marked double-dagger below the table

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

This value is several times the typical-state benchmark. It can be real, or it can be a coding artifact in what the facility submitted. Weigh it against the inspection record above.

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

0.08U.S. median 0.31
Therapy hours / resident / day
0.03hours / resident / day
Physical therapy
0.04hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.08 therapist hours per resident per day in 2026Q1 — more than 4% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 3% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNFnot reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF staynot reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFsnot reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

3.94
RN hours/ resident / day
2.39
LPN hours/ resident / day
3.77
Aide hours/ resident / day
10.10
Total nurse hours/ resident / day
3.62
RN hoursweekends
28.6%
Total nursing turnover
12.5%
RN turnover

How full it usually is: this home is certified for 22 beds and averages 19.4 residents a day — about 88% occupied, or roughly 3 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 10.10 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 3.94 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.77 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 9.19 hrs/resident/day on weekends vs 10.47 on weekdays — 12% thinner on weekends. RN hours go from 4.07 to 3.62 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 29% is below the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

9
deficiencies at the latest standard inspection (2026-06-11)
7
at the previous standard inspection (2025-04-25)

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

27 citations, most serious first. The 12 most serious are shown; the remaining 15 are one tap away and print in full.

  • Actual harm · Gcited before2024-03-07 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to meet professional standards of quality for 1 of 4 sampled (Patient 2), a pediatric patient who was unable to verbalize needs and unable to move extremities, did not suffer from burns of being laid on top of a heated humidifier tubing for unknown length of time. This deficient practice resulted in patient 2 suffering burn injury on his right arm and right back. Finding: A review of patient 2's admission record indicated the patient was originally admitted to the facility on [DATE] with admit diagnosis chronic respiratory failure (condition when lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body). A review of patient 2's History and Physical (H&P, a formal and complete assessment of the patient and the problem) dated 6/29/2023, the H&P indicated Patient 2's past medical history included Anisocoria eye's pupils are not the same size. Acute Hemorrhagic encephalomyelitis (a rare disorder that cause…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Actual harm · G2024-03-07 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure 1 of 4 sampled (Patient 2), a pediatric patient who was unable to verbalize needs and unable to move extremities, did not suffer from burns of being laid on top of a heated humidifier tubing for unknow length of time. This deficient practice resulted in patient 2 suffering burn injury on his right arm and right back. Finding: A review of Patient 2's admission record indicated the patient was originally admitted to the facility on [DATE] with admit diagnosis chronic respiratory failure (condition when lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body). A review of Patient 2's History and Physical (H&P, a formal and complete assessment of the patient and the problem) dated 6/29/2023, the H&P indicated Patient 2's past medical history included Anisocoria eye's pupils are not the same size. Acute Hemorrhagic encephalomyelitis (a rare disorder that cause rapid neurologic deterioration and…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-06-11 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to ensure proper food storage and infection control practices were implemented in accordance with the facility's Policy and Procedure (P&P) titled Standards for storing food and supplies, and Infection Control - Food and Nutrition Services by failing to: 1. Ensure thermometers were kept inside refrigerators 1 and 2. 2. Ensure a pitcher of pre-made iced tea was not left in the refrigerator beyond safe use by date of 6/8/2026. 3. Ensure Dishwasher (DW) 2 used the correct test strip to test for the quaternary ammonium (QUAT-a quaternary ammonium, a type of sanitizing solution used to sanitize food contact surfaces) sanitizer. 4. Ensure dishwashing machine temperature was checked for PM shift on 6/8/2026 and ensure the dishwashing machine thermometer is working appropriately. The deficient practice had the potential to place the facility's residents at risk to consume expired, spoiled and contaminated food and increased the risk for the facility's residents to develop food-borne illnesses (any sickness caused by…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-06-11 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not provide privacy for one of one sampled resident (Resident 1) reviewed for dignity when Resident 1's nephrostomy bag (a clear bag thatcollects your pee (urine) from your kidney) was exposed. This deficient practice had the potential to cause psychosocial (mental and emotional well-being) decline, resident's individuality, self-esteem, and self-worth. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE] with diagnoses including urinary tract infection (an infection in any part of your urinary system) and epileptical spasm (a rare but severe type of seizure). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 4/05/2026, the MDS indicated Resident 1's cognition (ability to understand and make decisions) could not be assessed. The MDS indicated Resident 1 was dependent (helper does all) with eating, oral hygiene, toileting,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-06-11 · tag F0605 — failed to not use drugs as a restraint — isolated
    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one (1) of five (3) sampled residents' (Resident 21) drug regimen was free from unnecessary medications (any medication in excessive dose, excessive duration, without adequate monitoring) in accordance with the facility's policy and procedure by failing to ensure: 1. Resident 21 had a specific, measurable target behavior related to the use of Sertraline (an antidepressant medicine used to treat depression [a serious mood disorder that causes persistent feelings of sadness, emptiness, and a loss of interest in activities]). 2. Resident 21 was monitored for the number of specific occurrences of behavior that was associated with the use of Sertraline. These deficient practices had the potential to place Resident 21 at risk for significant adverse effects (also known as side effects - undesired, unwanted, or dangerous effects that a drug may have, such as nausea and sleep problem) from the use of unnecessary antipsychotic drugs, which…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-06-11 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures to ensure the accurate acquiring, administering of drugs and biologicals to meet the needs for one (1) of three (3) sampled residents (Residents 16) observed for medication administration by failing to: Administer Resident 16's Miralax (a medication used to treat chronic constipation) with 4-8 ounces of water as ordered by the physician. Administer all of Resident 16's multivitamin This deficient practice resulted in Resident 16 not receiving medications as ordered by the physician, which could negatively affect the residents' overall wellbeing. Findings: During a review of Resident 16's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE] with diagnoses including hypertension (is when the pressure in your blood vessels is too high), pulmonary hypertension (high blood pressure in the arteries of the lungs). During a review of Resident 16's Minimum…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-06-11 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report to the physician irregularities (includes, but is not limited to, use of medications without adequate indication, without adequate monitoring, in excessive doses, and/or in the presence of adverse consequences, as well as the identification of conditions that may warrant initiation of medication therapy) and to address the use of Sertraline (an antidepressant medicine used to treat depression [a serious mood disorder that causes persistent feelings of sadness, emptiness, and a loss of interest in activities] and other mental health conditions) on the medication regimen review (MRR, or Drug Regimen Review, a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) for one of five residents (Resident 21) in accordance with the facility policy. These deficient practices had the potential to place Resident 21 at risk…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-06-11 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the facility's medication error rate was less than five (5) percent (%). Two (2) medication errors (the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order/ manufacturer's specifications / accepted professional standards and principles) out of 25 opportunities (observed administered medications) for error, to yield an overall medication error rate of 8 % for one (1) of three (3) sampled residents (Resident 16) observed during medication administration (med pass). This deficient practice had the potential to result in adverse reactions (undesired effect of a drug or other type of treatment), ineffective treatment, worsening of Resident 16's condition, or potentially serious harm or injury. Findings: During a review of Resident 16's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE] with diagnoses including…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-06-11 · tag F0802 — failed to prepare enough nourishing food — isolated
    Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure one of ten dishwashers were competent in their duties when Dishwasher 2 (DW 2) did not know the proper sanitizer test strip to use for the quaternary ammonium (QUAT-a quaternary ammonium, a type of sanitizing solution used to sanitize food contact surfaces) sanitizer and when DW 2 did not know the procedure for testing strength of the quaternary ammonium sanitizer. This deficient practice had the potential to result in unsafe and unsanitary food production and could affect residents who were served food from the facility kitchen. During a concurrent kitchen tour and interview on 6/9/2026 at 10:23 AM with the Director of Food and Nutrition Services (DFN), two sink areas were observed. The DFN stated, there is one three-compartment sink area where they clean and sanitize cooking pots and pans manually (by hands) and another separate area where they clean and sanitize the residents' dishes and utensils using the dishwasher. During a concurrent observation and interview on 6/9/2026 at 10:38 AM with…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-06-11 · tag F0868 — isolated
    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility's failed to meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program, and ensure the required committee members (Thedirector of nursing (DON), The Medical Director or his/her designee, The Infection Preventionist (IP), and at least three other staff, one of whom must be the facility's administrator, owner, board member) were inregular attendance of the facilities quality assessment and assurance (QAA) meetings. This deficient practice had the potential to affect all of the facilities 22 residents residing in the facility. Findings: During an interview on 6/11/2026 at 12:45 PM with Chief Nursing Officer (CNO), CNO stated she was covering for the facilities DON since the DON was on leave since May 2026. CNO stated the facilities last QAA meeting had been held in May but she was unable to attend due to scheduling conflicts. During a concurrent interview and record review on 6/11/2026 at 12:45 PM with CNO of the facility's QAA meeting attendance sign in sheets were reviewed. The sign in sheets…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-06-11 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to review the infection prevention and control program (IPCP) annually in accordance with the facility's policies and procedures (P&P) titled, Pediatric Subacute Infection Prevention Program 2024-2025. The deficient practice had a potential for the IPCP to fail in ensuring quality and compliance with recommended guidelines and practices. During an interview on 6/10/2026 at 1:25 PM with the Infection Prevention Nurse (IPN), the IPN stated, the facility's infection control policies and procedures are reviewed every three (3) years. The IPN stated she could not remember the last time she reviewed the facility's infection prevention and control program (IPCP). During concurrent interview and record review on 6/11/2026 at 3:15 PM with the Chief Nursing Officer (CNO), the facility's Pediatric Subacute Infection Prevention Program 2024-2025, undated, was reviewed. The IPCP indicated the program was developed for the year 2024-2025. The CNO stated they are using an outdated IPCP, and the IPCP should be reviewed and revised in 2025 to…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-16 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure its staff adhere to the facility's infection control program in accordance to its policy and procedure when three of three sampled residents were found to have a positive rhinovirus (a common cause of the common cold) result within a four day period. This deficient practice had the potential to result in putting residents and staff at risk for more transmissions of infections within the facility.During a record review of Resident 1's History and Physical (H&P), dated 09/02/2025, the H&P indicated Resident 1 was admitted to the facility on [DATE]. The H&P indicated Resident 1's medical history included, but was not limited to, Trisomy 21 (a genetic condition that causes intellectual delays and potential health issues like heart defects), cerebral palsy (a group of permanent disorders affecting movement, muscle tone, and posture caused by damage to the developing brain, typically before birth), global developmental delay (a condition which shows…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
Show the remaining 15 citations
  • Potential for harm · Ecited before2025-04-25 · tag F0693 — failed to provide proper feeding-tube care — pattern
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the head of bed for two (2) of three (3) sampled residents (Resident 2 and Resident 11) was maintained at 30 to 45 degrees (unit of measurement) while receiving gastrostomy tube (g-tube, a small tube inserted through a surgical opening in the abdomen directly into the stomach used to deliver nutrition, fluids, and medications to individuals who cannot eat or drink safely through their mouth) feeding, in accordance with the physician's order and facility's policy and procedure. This deficient practice had the potential to cause complications including aspiration (a medical sense, occurs when food, liquid, or foreign objects enter the airway and lungs) that can lead to hospitalization and death. Findings: 1. During a review of Resident 2's admission Record, the admission Record indicated Resident 51 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnoses included anoxic brain damage (occurs…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-04-25 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure the food service area was maintained in a clean, sanitary, and functional manner while providing proper food handling in accordance with the facility's policy and procedure by failing to ensure: 1. One refrigerator (Refrigerator #10) was clean, without water drippings, and was not rusted (a form of corrosion visible on steel surfaces exposed to moist). 2. One can opener was not chipped and rusted. 3. The food processor was in good condition and without a brown, black to yellowish discoloration and calcium build ups (hard crusty deposit on surfaces and/ equipment). These deficient practices had the potential to result in pathogen (germ) exposure to residents, which could place the residents at risk for developing foodborne illness ([food poisoning] with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever) and can lead to other serious medical complications and hospitalization. Findings: 1. During an observation on 4/22/2025 at 7:48 AM in the facility kitchen,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-04-25 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to observe infection control measures for one of four sampled residents (Resident 13) by failing to ensure that the Staff 1 washed hands after touching the floor while picking up the table napkin and continued to assist on feeding Resident 13. This deficient practice had the potential to transmit infectious microorganisms (microbes that are temporarily harbored on the superficial surface of the body) and increase the risk of infection for the residents. Findings: During a review of Resident 13's admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE] and was re admitted on [DATE] dysphagia (difficulty swallowing), seizure (sudden burst of electrical activity in the brain), chronic respiratory failure (not enough oxygen travels from the lungs into the blood). During a review of Resident 13's Minimum Data Set (MDS- a resident assessment tool), dated 2/9/2025, the MDS indicated the resident…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-04-25 · tag F0921 — failed to keep a safe, functional, sanitary building — pattern
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain a safe, clean, comfortable, sanitary and environment by: 1. Facility failed to ensure three (3) of six (6) restroom sinks (rooms [ROOM NUMBER]) have no yellowish, brownish, and chipped sideboard. 2. Facility failed to ensure the table in activity classroom was in good condition and did not have edges that were peeling off, exposing the wood part of the table and chipped off leaving sharp and rough edges 3. Facility failed to ensure the trash can in room [ROOM NUMBER] was not overflowing. These deficient practices caused an unsanitary and had potential for residents to be placed at risk of injury and/ or infection. Findings: 1. During an observation on 4/22/2025 at 10:02 AM in room [ROOM NUMBER]'s restroom, the back splash in the restroom was damaged. Observed that the linoleum was lifted exposing the wound underneath and the sink has yellowish, brownish colored substance and the sideboard was chipped. During an observation on…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-25 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. During a review of Resident 11's admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE] and was re admitted on [DATE] with congenital ( a condition or trait that exists at birth) hypoplasia and dysplasia of lung (condition where the baby's lungs have not fully developed) , chronic respiratory disease (diseases that affect the lungs and airways), encounter for attention to gastrostomy (G-tube, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 11's MDS, dated [DATE], the MDS indicated the resident was severely impaired with cognitive skills for daily decision making. Resident 11 was dependent on transfers (how resident moves to and from bed, chair and wheelchair), eating, dressing, and personal hygiene. The MDS also indicated Resident 11's respiratory treatments included oxygen therapy, suctioning, and tracheostomy care while in the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-25 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of one of four sampled residents (Resident 17) in accordance with the facility policy by failing to administer Resident 17's 8 AM due medications on 4/25/2025 as indicated on the physician's order. This deficient practice had the potential for Resident 17 to experience tachycardia (a fast heartbeat of more than 100 times per minute), high blood pressure (when your blood pressure is consistently higher than normal), pain and decline in overall health status. Findings: During a review of Resident 17's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE]. Resident 2's diagnoses included chronic respiratory failure with hypoxia (a condition where the body cannot get enough oxygen). During a review of Resident 17's Minimum Data Set (MDS, a resident assessment tool), dated 4/13/2025, the MDS indicated Resident 17's cognitive (ability to…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-25 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Cross reference: F755 Based on observation, interview, and record review, the facility failed to ensure its medication error rate was less than five (5) percent (%). Seven (7) medication errors (the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order/ manufacturer's specifications / accepted professional standards and principles) out of 30 opportunities (observed administered medications) for error, which yielded a facility medication error rate of 23.33 % for one (1) of four (4) sampled residents (Resident 17) observed during medication administration (med pass). Resident 17's scheduled 8 AM medications were not administered timely as indicated on the physician's order and facility policy. This deficient practice had the potential to result in adverse reactions (an undesired harmful effect resulting from a medication or other intervention) to Resident 17. Findings: During a review of Resident 17's admission Record, the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-30 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure one of four resident's skin integrity was assessed and treated by wound care services when consulted by nursing staff in accordance with the facility's policy and procedure. This failure resulted in Resident 1's persistent redness to the chest area for five days, which did not get assessed and treated by wound care services, which compromised Resident 1's health and well-being. Findings: During a review of Resident 1's History and Physical (H&P), dated 9/21/23, the H&P indicated that Resident 1 was an 8-month-old patient with a medical history including chronic lung disease, tracheostomy (an incision in the windpipe made to aid in breathing), and ventilation (a machine aiding in air exchange in and out of the lungs) dependent. During a review of Resident 1's Patient Progress Notes (an ongoing record of a patient's illness and treatment), dated from 7/20/24 through 7/25/24, the progress note indicated the following: On 7/20/24 at 5:02 p.m., the nursing notes indicated, Pt (Patient 1) has multiple scratches and red…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-04-14 · tag F0578 — failed to honor advance directives / code status — pattern
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure two (2) of 4 sampled residents (Residents 15 and 19) had a completed advanced directive acknowledgment form (a form indicating to the resident or responsible party the right to give written directions about future treatment before becoming seriously ill or unable to make healthcare decisions). This deficient practice had the potential to result in misinformation of medical care and treatment and not honoring resident's wishes in cases where the resident and/or responsible party was unable to participate in making healthcare decisions. Findings: 1. A review of Resident 15's admission Record indicated the resident was readmitted to the facility on [DATE], with diagnoses that included anoxic brain damage (a brain injury caused by lack of oxygen to the brain resulting in brain cells death). During a concurrent interview and record review on 4/13/2024 at 12:40 PM, with the Social Services Director (SSD) of Resident 15's medical records, the SSD stated…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-04-14 · tag F0693 — failed to provide proper feeding-tube care — pattern
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide the appropriate care to four of four sampled residents (Resident 4, 9, 11, and 12) who had a gastrostomy tube (G-Tube, a tube placed directly into the stomach through an abdominal wall incision for the administration of food, fluids, and medications) by failing to: 1. Ensure the tube feeding syringe was labeled with date opened for Resident 4, 9, 11, and 12. 2. Ensure a new bottle of Peptide-Based Nutrition ( nutritional formula) was used for Resident 4, feeding was used for more than 24 hours. These deficient practices placed Resident 4, 9, 11, and 12's G-tube at risk for getting clogged and contaminated which had the potential to cause discomfort and infection. Findings: 1a. A review of Resident 9's admission record indicated an admission to the facility on 1/1/2024 with a diagnosis of atresia (absence or abnormal narrowing of an opening or passage in the body) of foramina (an opening that allows passage of structures from one…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-04-14 · tag F0756 — failed to review each resident's drug regimen — pattern
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Attending Physician (AP) reviewed the drug regimen thoroughly and documented in the resident's medical record if the identified irregularities and recommendation of the pharmacyst were accepted, rejected and a rationale was documented if the Pharmacist recommendations in the Medication Regimen Review (MRR)were accepted or rejected for four of four sampled residents (Resident 3, 5, 9, and 10). This deficient practice had the potential for the residents to receive excessive or insufficent dosage of medications that the could harm the residents and/or not receive the right medication to treat the resident's underlying medical condition due to the missed opportunity to act upon the reported irregularities. Findings: 1. A review of Resident 9's admission record indicated an admission to the facility on 1/1/2024 with a diagnosis of atresia (absence or abnormal narrowing of an opening or passage in the body) of foramina (an opening that allows…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-04-14 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage, labeling of food, and preparation practices in the kitchen, in accordance with the facility's policy and procedures on Cleaning Schedule Use and Cleaning of Equipment. 1. One opened unlabeled plastic container with a single ice cream cone was found in the freezer. 2. Food particles found inside the freezer floor. 3. A bundle of wilted black colored cilantro (leafy vegetable) and molded jicama (fruit) were found in the refrigerator. 4. Open, unlabeled and undated personal beverage cup found in the kitchen food prep area. These deficient practices had the potential to put residents at risk for foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins). Findings: During the initial observation of the facility's kitchen freezer on 4/12/2024 at 11:52 AM, one opened unlabeled plastic container with a single ice cream cone was found in the freezer shelve, and pieces of unknown food particles was observed inside the freezer floor.…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-04-14 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. A review of Resident 13 ' s admission record indicated an admission to the facility on 1/1/2024, with a diagnosis of Di [NAME] ' s syndrome (a chromosomal or form of genetic disorder that results in poor development of several body systems). A review of Resident 13 ' s MDS dated [DATE], indicated Resident 13 had diagnoses that included seizure disorder (a disorder in which nerve cell activity in the brain is disturbed, causing seizures.), asthma (a condition in which a person's airways become inflamed, narrow and swell, and produce extra mucus, which makes it difficult to breathe). During an observation on 4/12/2024 at 12:30 PM, the facility ' s unit entrance signage was observed indicating N95 mask must be worn in all patient care areas. During an observation of Resident 13 ' s room on 4/12/2024 at 12:59 PM, a contact precaution signage was observed prior to entering the resident ' s room. The signage indicated everyone must clean their hands, including before entering and when leaving the room, to put on…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-14 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to develop and implement individualized person-centered care plans with measurable objectives, timeframes and interventions for one of two sampled resident's (Resident 15) with urinary catheter (a device that drains urine from the urinary bladder into a collection bag). This deficient practice had the potential for Resident 15 not to receive appropriate care, treatment and/or services. Findings: A review of Resident 15's Face Sheet indicated the resident was readmitted to the facility on [DATE], with diagnoses that included anoxic brain damage (a brain injury caused by lack of oxygen to the brain resulting in brain cells death). A review of Resident 15's Minimum Data Set (MDS, a standardized resident assessment and care planning tool) dated 3/10/2024, indicated Resident 15 had diagnoses that included neurogenic bladder (a person lacks bladder control due to brain, spinal cord or nerve problems), and urinary tract infection (UTI, an infection…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-14 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 13): 1. Resident 13's aerosol, oxygen system(a medical device is used to convert the medication into fine aerosol particles which can be inhaled or propelled directly into the airway and lungs) was dated with the date it was changed, in accordance with the facility ' s policy and procedure on Respiratory Equipment Handling. 2. Resident 1's tracheostomy mask (a soft plastic mask that fits over the trachea opening) was stored in a plastic bag when not in use, for infection control. This deficient practice placed the Resident 13's respiratory equipment at risk for contamination and Resident 13 at risk for infection. Findings: A review of Resident 13's admission Record indicated an admission to the facility on 1/1/2024, with a diagnosis of Di [NAME] ' s syndrome (a chromosomal disorder that results in poor development of several body systems). A review of Resident 13's Minimum Data Set (MDS, a…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleSince
Ownership Data Not Available

The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.

What families pay in CA

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the California Medicaid page.

Typical monthly cost in California
$12,167/mo
Nursing home (semi-private)
$15,178/mo
Nursing home (private)
$7,000/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 555589. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-06-11, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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